What is the recommended diet for patients with alcoholic hepatitis?

Nutritional Management for Alcoholic Hepatitis

Patients with alcoholic hepatitis require high-calorie (35-40 kcal/kg/day) and high-protein (1.2-1.5 g/kg/day) diets with additional meals when standard three meals are inadequate, along with comprehensive vitamin and mineral supplementation. 1

Nutritional Assessment and Requirements

• Energy requirements:

  • Standard patients: 35-40 kcal/kg/day 1
  • Critically ill patients: 40 kcal/kg/day 1
  • Obese patients: Reduced target of 25 kcal/kg/day 1

• Protein requirements:

  • Standard patients: 1.2-1.5 g/kg/day 1
  • Critically ill patients: 1.5 g/kg/day 1
  • Obese patients: Increased target of 2.0 g/kg/day 1

• Meal frequency: If three meals per day do not provide adequate nutrition, additional meals in the early morning and late evening are recommended to restore nutritional balance 1

Nutritional Support Strategies

Oral Nutrition

• First-line approach for all patients who can eat
• Late evening snacks are particularly important to reduce overnight fasting 1
• Caloric intake below 21.5 kcal/kg/day is associated with higher mortality 1

Oral Nutritional Supplements (ONS)

• Should be offered to all patients with severe alcoholic hepatitis who cannot meet requirements through spontaneous food intake 1
• Particularly beneficial as late evening or nocturnal supplements 1
• Improves survival, infection rates, liver function, and resolution of encephalopathy 1

Enteral Nutrition

• Should be used when patients cannot meet caloric requirements through normal food and/or ONS 1
• Associated with improved survival and reduced infectious morbidity 1
• Should be initiated within 12-24 hours postoperatively after liver transplantation 1

Micronutrient Supplementation

Vitamin and mineral supplementation should be provided along with nutritional therapy 1. Specific supplements include:

• Vitamin A
• Thiamine (essential to prevent Wernicke's encephalopathy)
• Vitamin B12
• Folic acid
• Pyridoxine
• Vitamin D
• Zinc

Special Considerations

Severe Alcoholic Hepatitis

• Malnutrition is present in 50-100% of patients with severe alcoholic hepatitis 1
• Malnutrition is an independent predictor of mortality 1
• Reduced supplemental nutrition improves infection rates and in-hospital mortality 1

Hepatic Encephalopathy

• Consider parenteral nutrition in patients with unprotected airways and hepatic encephalopathy when cough and swallow reflexes are compromised 1
• Long-term supplementation with branched-chain amino acids improves hepatic encephalopathy 1

Implementation Challenges

Despite clear recommendations, adherence to appropriate nutrition in acute alcoholic hepatitis is often low (only 17% in one study) 2. Strategies to improve compliance include:

• Mandatory hepatology consultation (improved nutrition compliance from 8.3% to 21%) 2
• Nutrition service consultation (improved nutrition compliance to 67%) 2
• Protocolized care for appropriate nutrition 2

Importance of Abstinence

While nutrition is critical, complete abstinence from alcohol is the most important treatment for alcoholic hepatitis 1, 3. Nutritional therapy should be implemented alongside abstinence counseling and support.